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ONIT NG SYSTEM CERTIRCATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: RAMOS OIL Bldg. No.: Site Address: 10842 S. HARLAN ROAD City: FRENCH CAMP I Zip: 95231 Facility Contact Person: DAVE NELSON Contact Phone No.: (916)371-3289 Make/Model of Monitoring System: INCON TS-1000 EF1 Date of Testing/Servicing: OCT 1, 2009 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: Tank ID:DIESEL Tank ID: Z In-Tank Gauging Probe. Model: TSP-LL ❑In-Tank Gauging Probe. Model: Z Annular Space or Vault Sensor. Model: TSP-HLS ❑Annular Space or Vault Sensor. Model: ®Piping Sump/Trench Sensor(s). Model: TSP-ULS ❑Piping Sump/Trench Sensor(s). Model: Z Fill Sump Sensor(s). Model: TSP-ULS ❑Fill Sump Sensor(s). Model: Z Mechanical Line Leak Detector. Model: FX/V/LD 2000 ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Z Tank Overfill/High-Level Sensor. Model:FLAPPER ❑Tank Overfill/High-Level Sensor. Model: ❑ Other(s2ecify equipment a and model in Section E on Pae 2 . ❑Other(specify equipment ty e and model in Section E on Pae 2). Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Others eci equipment e and model in Section E on Pa e 2). ❑Other(specify e ui ment e and model in Section E on Pae 2). Dispenser ID: 1A Dispenser ID: 11®2 Z Dispenser Containment Sensor(s). Model: TSP-ULS Z Dispenser Containment Sensor(s). Model: TSP-ULS Z Shear Valve(s). Z Shear Valve(s). ❑ Dispenser Containment Floats and Chain (s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID:3A &2A Dispenser ID: 3&4 Z Dispenser Containment Sensor(s). Model: TSP-ULS Z Dispenser Containment Sensor(s). Model: TSP-ULS Z Shear Valve(s). Z Shear Valve(s). ❑Dis enser Containment Floats and Chain (s). ❑Dispenser Containment Floats and Chain (s). Dispenser ID:5A &4A Dispenser ID: 5 Z Dispenser Containment Sensor(s). Model: TSP-ULS Z Dispenser Containment Sensor(s). Model: TSP-ULS Z Shear Valve(s). Z Shear Valve(s). ❑Dis enser Containment Float(s)and Chain(s). ❑Dispenser Containment Floats and Chains . *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to the Certification is information(e.g. manufacturers' checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report; (check all that apply): Z System set-up Z Alarm history report Technician Name(print): RICHARD THOMAS Signature: � ___-_k Certification No: 957353761 License: 803705 Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION I Phone No: (707)446-6151 Address: 607 ELMIRA RD, PMB 336, VACAVILLE, CA 95687 Date of Testing/Servicing: OCT 1, 2009 Pagel of 3 Monitoring System Certification